743 Jefferson Avenue Suite 203 Scranton, Pennsylvania
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- Abigayle Henry
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1 743 Jefferson Avenue Suite 203 Scranton, Pennsylvania Name: DOB: / / Age: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Reason for your visit today: Who referred you to our practice? PAST MEDICAL HISTORY: Have you ever had or do you now have any of the following medical conditions? Heart Disease Mitral Valve Prolapse Rheumatic Fever Respiratory problems Asthma Diabetes Kidney Disease High Blood Pressure Phlebitis/Blood Clots Bleeding Disorders Thyroid Problems Glaucoma Cataracts Seizure Disorders Other: Gallbladder Disease Hepatitis Liver Disease Depression Anxiety Esophageal Reflux Diverticulitis Colitis High Cholesterol Osteopenia Osteoporosis Cancer/Type: Migraines: ALLERGIES/REACTIONS, including any LATEX allergies: MEDICATIONS: Please list ALL medications, supplements, and herbs you are currently taking; including hormones: I give my permission to upload my medication history from my pharmacy: PAST SURGICAL HISTORY: Include any and all surgeries from birth to present time. YEAR TYPE OF SURGERY COMPLICATIONS
2 PREGNANCY HISTORY: Number of pregnancies: Number of living children: Number of miscarriages: Number of terminations: DATE TYPE OF DELIVERY SEX WEIGHT COMPLICATIONS First day of your last period: Age with your very first period: When NOT on hormonal control: How frequently do you have a period? Amount of days you bleed: Age with first intercourse: Number of partners/lifetime? GYNECOLOGY HISTORY: History of Sexually Transmitted Infections? What type? What do you use to prevent pregnancy? If Postmenopausal, what year did you stop having your periods? Any history of abnormal Paps? When? Diagnosis: Cervical surgery? Colposcopy: LEEP/Cyro: Last Pap Smear: Last Mammogram: Last Bone Scan: Last Colonoscopy: Do you experience any of the following? Bleeding between period? Heavy periods - changing pad or tampon every hour? Painful periods? Bleeding after intercourse? Pain with intercourse? Prolapse (Falling of pelvic organs)? SOCIAL HISTORY: Do you smoke cigarettes? If yes, how many per day? For how many years? Do you drink alcohol? If yes, how frequently? Daily Weekends Socially Do you use street/illegal drugs? If yes, what kind? How often? VACCINATIONS: Last Influenza Vaccination: Last Pneumovax Injection: Did you recieve HPV vaccine?: Have you ever taken hormone replacement in the past? What: When: For how many years: Have you ever had bleeding after menopause? If so, when: FAMILY HISTORY: List ANY family members (Grandparents/Parents/ Siblings/Children) that have the following conditions. Heart Disease: Stroke: Bleeding Disorder: High Blood Pressure: Kidney Disease: Diabetes: Osteoporosis: Other: Cancer (What type?): Reviewed by: Date:
3 743 Jefferson Avenue Suite 203 Scranton, Pennsylvania Name: Date of Birth: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Address: SSN: Marital Status: Primary Care Physician: Pharmacy: Occupation: Spouse s Name: Phone: Phone: Employer: Employer: Emergency Contact: Relationship: Phone: Assignment and Release I authorize the release of medical information to process claims for serviced rendered, and I also authorize the payment of medical benefits directly to Dr. Barbara Plucknett. Signature of Insurer/Guardian Date Medicare Insurance Agreement I authorize the holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration of its intermediaries or carriers any kind of information needed for this or a related claim. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits either to myself of to the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply. Signature of Insurer/Guardian Date
4 743 Jefferson Avenue Suite 203 Scranton, Pennsylvania VOIDING DIARY This paperwork MUST be completed prior to your appointment. If not, your appointment will need to be rescheduled. If you have any questions, please call our office. This chart is a record of your voiding (urination and leakage incontinence) of urine. Please complete this according to the following instructions from our office. Choose a 24 hour period to keep this record when you can conveniently measure every voiding and begin your record with first voiding upon arising as in the sample below. EXAMPLE: Column #1 TIME Column #2 VOIDED Column #3 LEAK Column #4 URGE PRESENT Column #5 ACTIVITY Column #6 AMOUNT/TYPE INTAKE 6:45 AM 550 CC awaking 7:00 AM 2 YES turned on water 2 cups coffee 6 oz orange juice 5:00 PM 120 CC 1 cup tea Column #1 TIME: Record time of all voids, leakage, intake of liquids. Column #2 VOIDED: Measure all intake and output in cc s or oz s. Column #3 LEAK: Estimate the amount of leakage according to the following scale: 1 = damp, few drops only 2 = wet underwear or pad 3 = soaked or emptied pad Column #4 URGE PRESENT: If the urge to urinate was accompanied by the urine leakage, write YES. If you felt no urge when the leakage occurred, write NO. Column #5 ACTIVITY: Describe activity you were performing at the time of leakage. If you were not actively doing anything, record whether you were sitting, standing, or lying down. Column #6 AMOUNT/TYPE INTAKE: Record the amount and type of all liquid intake using cc s or oz s (1 cup = 8 oz = 240 cc).
5 Patient s Name Date of Birth VOIDING DIARY/UROLOG TIME VOIDED LEAK URGE PRESENT ACTIVITY AMOUNT/TYPE INTAKE
6 Name: Date: INSTRUCTIONS TO PATIENT Please check the ( ) if your answer is YES 1. Have you had treatment for urinary tract disease such as: stones ( ) kidney disease ( ) infections ( ) tumors ( ) injuries ( ) 2. Have you ever had: paralysis ( ) back pain ( ) polio ( ) syphilis ( ) multiple sclerosis ( ) diabetes ( ) stroke ( ) pernicious anemia ( ) 3. Have you had an operation on your: spine ( ) brain ( ) bladder ( ) 4. Have you had a bladder infection during the last year? ( ) 5. If yes, did it occur more than twice during the last year? ( ) 6. Did the bladder infection follow intercourse at any time? ( ) 7. Is your urine ever bloody? ( ) 8. Have you ever been treated by urethral dilatation? ( ) 9. If yes, when? How many times? 10. Did urethral dilatation help you? ( ) 11. Did you have trouble holding urine as a child? ( ) 12. As a child, did you wet the bed? ( ) 13. If yes, at what age did you stop? 14. Do you wet the bed now? ( ) 15. What is the volume of urine you usually pass? large ( ) small ( ) medium ( ) very small ( ) 16. Do you notice any dribbling of urine when you stand after passing urine? ( ) 17. Do you lose urine by spurts during severe: coughing ( ) sneezing ( ) vomiting ( ) 18. If yes, in which positions does it occur? standing ( ) sitting ( ) laying down ( ) 19. Do you lose urine without coughing, sneezing, or vomiting? ( )
7 20. If yes, when does it occur? walking ( ) any change of position ( ) running ( ) after intercourse ( ) straining ( ) during intercourse ( ) lying down ( ) 21. When you are passing urine, can you usually stop the flow? ( ) 22. Did your urine difficultly start during: pregnancy ( ) after delivery of an infant ( ) 23. Did it follow an operation? ( ) 24. If yes, check the type of operations: Hysterectomy (removal of womb), through the vagina Suspension of the uterus or bladder Removal of a tumor through the abdomin Cesarean section Vaginal repair operation Other 25. Did it follow X-RAY treatment? ( ) 26. If your menstrual periods have stopped, did menopause make your condition worse? ( ) 27. Do you lose control and pass a large amount of urine when you: cough ( ) vomit ( ) sneeze ( ) after intercourse ( ) lift ( ) during intercourse ( ) strain ( ) 28. Do you have difficulty holding urine if you suddenly stand up after sitting or lying down? ( ) 29. Do you find it necessary to wear protection because you get wet from the urine you lose? ( ) 30. If yes, at what age did you start using this protection? 31. When do you wear protection? occasionally ( ) only during the day ( ) all the time ( ) only at night ( ) 32. Is your urinary problem bad enough that you would request surgery to fix it? ( ) 33. List all medications you are now taking and duration of use of each medication Medication Dose Direction Of Use 34. When you lose your urine accidentally, are you ever unaware that it is passing? ( ) 35. Do you have to hurry to the bathroom or can you take your time? Hurry ( ) Take time ( ) 36. Can you overcome the uncomfortably strong need to pass urine? Usually ( ) Occasionally ( ) Rarely ( ) 37. Can you overcome the uncomfortably strong need to pass urine with a full bladder? ( ) 38. Do you have an uncomfortably strong need to pass urine without a full bladder? ( ) 39. How many times do you void during the night after going to bed?
8 40. How many times do you void during the first hour after going to bed? 41. Does an uncomfortably strong need to pass urine wake you up? ( ) 42. Are you usually awake and simply pass urine while up? ( ) 43. After passing urine, can you usually go back to sleep? ( ) 44. How much fluid do you usually drink before going to bed? cups. 45. Do you have discomfort in the area above or the side of your bladder? ( ) 46. Do you have pain while you pass your urine? ( ) 47. Is it painful during the entire time you pass urine? ( ) 48. Is it painful only at the end of passing urine? ( ) 49. Do you always feel that your bladder is empty after passing urine? ( ) 50. Do you usually have painful passing of urine after intercourse? ( ) 51. Do you need to pass urine more frequently after intercrouse? ( ) 52. Does your bladder discomfort stop completely after passing urine? ( ) 53. How often do you pass urine during the day? Every hours. 54. Do you need to pass urine more frequently while riding in a car? ( ) 55. Are you ever suddently aware that you are losing or are about to lose control of your urine? ( ) 56. How often does this occur? /Day /Week 57. Does the sound, the sight, or the feel of running water cause you to lose urine? ( ) 58. Is your clothing slightly: damp ( ) wet ( ) soaking wet ( ) leave puddles on floor ( ) 59. Is your loss of urine a continual drip so that you are constantly wet? ( ) 60. Do you usually have difficulty starting your urine stream? ( ) Summary: Briefly state your urinary problem:
743 Jefferson Avenue Suite 203 Scranton, Pennsylvania VOIDING DIARY. Column #3 LEAK
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PATIENT INFORMATION PLEASE NOTE: This file must be saved to your desktop before and after completing! Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number
Welcome to Medina Family Chiropractic and Acupuncture!
Welcome to Medina Family Chiropractic and Acupuncture! Please fill out this form and return it to the front desk. Let us know if you have any questions! Personal information Date: First name: Middle name:
Health Questionnaire
Patient Name Date of Birth Thank you for choosing Southern Cancer Center for your care. To help us best prepare for your appointment, please complete this form and bring it to your appointment. If you
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Please take a few minutes and complete the following questions before you see the doctors so that we may learn a bit more
Patient History. Name Age Date. 2. When did your problem first begin?
Patient History Name Age Date 1. Describe the problem that brought you here? 2. When did your problem first begin? 3. Was your first episode of the problem related to a specific incident/injury? Yes/No
Women s Health Associates Maitland
Doctors Name First Name Last Name Preferred first name. Marital Status Date of Birth Street Suburb Postcode State Email Address Home telephone Work Telephone Mobile Number Please indicate how you would
Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address
Today s Date Contact Information Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address Phone numbers and E-mail (please check numbers to call or leave a message) Home
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
GIDEON G. LEWIS, M.D.
GIDEON G. LEWIS, M.D. Date: LAST Name: FIRST Name: MIDDLE Initial: Address: City: State: Zip Code: Date of birth: / / Social Security #: - - Sex: M F Marital Status (Circle): Single Married Divorced Widowed
Avery Acupuncture & Natural Medicine New Patient Registration
Welcome to Avery Acupuncture & Natural Medicine. Our goal is to make your experience here as comfortable as possible. If you have any questions, comments, concerns or suggestions, please let Veronica or
AUTHORIZATION TO RELEASE AND/OR OBTAIN PATIENT INFORMATION
Medical Record # Patient Name(s) Date of Birth Social Security # Contact Phone # AUTHORIZATION TO RELEASE AND/OR OBTAIN PATIENT INFORMATION OBTAIN FROM: (Releasing facility) RELEASE TO: (Receiving entity)
New Patient Paperwork
Name (Last, First, M.I.): M F Email Address: Primary Phone: Race: Today's Date: DOB: Alternate Emergency Phone: Contact: American Indian/Alaska Native Asian African American Caucasian Nat Hawaiian/Pacific
Health screening questionnaire
Health screening questionnaire High Road Buckhurst Hill Essex IG9 5HX Tel: 020 8936 1202 Fax: 020 8936 1191 Visit: theholly.com Title: Surname: Forenames: Date of birth: Age: Address: Tel no. (Home): Tel
Name DOB Age Date Address Phone
Patient History Name DOB Age Date Address Phone E-mail 1. Describe the current problem that brought you here: 2. When did your problem first begin? 3. Was your first episode of the problem related to a
PATIENT INFORMATION FORM (PLEASE PRINT)
PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / / PATIENT NAME: LAST FIRST MI DATE OF BIRTH: / / AGE: SEX: M F HOME ADDRESS: CITY/STATE: ZIP: MAY WE LEAVE A MESSAGE? HOME PHONE #: ( ) - YES NO WORK PHONE
Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code
Name Age Date Address Phone What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician Address Street Address City State Zip Code PAST MEDICAL HISTORY:
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE
Neurology East 48 Medical Park Dr. East Richard G. Diethelm, MD Suite 351 Andrea Sutton, RN, MSN, ANP- BC Birmingham, AL 35235 (205) 836-9366 www.neurologyeast.com NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW-
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM Patient Information (Please print) Last Name: First Name: Middle Initial: Name you prefer to be called: of Birth: / / Social Security #: Gender: M F Address: City: State: Zip:
Questionnaire for Incontinent Patients
Questionnaire for Incontinent Patients Name Date: Date of birth: weight: height: Vaginal deliveries: Caesarean Sections: profession: No Yes Sometimes Yes 50% or more Do you lose urine during sneezing or